Billing and Coding: Vitamin B₁₂ Injections

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33967 Vitamin B 12 Injections. Please refer to the LCD for reasonable and necessary requirements. Coding Guidelines Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. Progress notes and laboratory test results indicating present or past values of serum B 12 as well as supporting the treatment for the identified diagnosis(es) need to be maintained and made available upon request in the event a review is required. A serum B 12 level is not required if vitamin B 12 is administered in conjunction with pemetrexed or pralatrexate. The medical record should reflect the patient is being treated with pemetrexed or pralatrexate.